Pain Assessment and Management, 2nd Edition _ _________________________________________________
Manual Therapy Manual therapy techniques are hands-on methods of affecting the musculoskeletal systems of the body. In pain management, often the pain itself—rather than the cause of the pain—is treated. Manual therapy techniques are used to improve mus- culoskeletal functions and reduce pain (Obaya et al., 2022). Manual therapy techniques include the following: • Proprioceptive neuromuscular facilitation— stimulating proprioception of the nerve-muscle unit to facilitate strength, flexibility, and coordinated movement patterns • Joint mobilization—rhythmic, oscillatory movement of the joint within the physiological range by stretching the soft tissues surrounding a joint, which helps improve joint mechanics and decreases pain • Soft tissue mobilization—therapeutic massage, myofascial release, and instrument-assisted massage are used to improve muscle relaxation, increase blood flow, stretch soft tissues, and break down adhesions The efficacy of manual therapy for chronic musculoskeletal pain is supported. However, a recent meta-analysis by Ezzatvar et al. (2024) found that while manual therapies are clinically effective, the effects were not specifically a result of the interven- tion. They found that nonspecific factors including therapist- patient interaction, placebo effect, or the patient’s mindset influence the outcomes. Austin (2018) reports moderate to moderate-high levels of evidence for a number of conditions. See Table 7 for information that is more specific.
the neural pathways. In theory, the stimulation of the large beta nerve fibers, which transmit deep pressure and touch impulses, closes the gate, and blocks painful impulses carried by smaller A-delta and C fibers from being perceived by the brain (Kirkpatrick et al., 2015). According to the endorphin theory, TENS may cause the release of natural endorphins and serotonin to raise the client’s pain threshold. Intensity is an essential parameter for identifying the dose and the effect; however, it continues to be difficult to control this subjective factor of “strong but comfortable” for the most effective pain relief (Serrano-Muñoz et al., 2017). Multiple guidelines include the use of TENS for the treatment of chronic low back pain, with the greatest effect coming from a treatment duration of less than five or six weeks (Jauregui et al., 2016; Wu et al., 2018). In a review of the literature, Meroni et al. (2021) found that TENS is not supported for chronic low back pain and is not recommended for use in primary care. Verville et al. (2023) report that the little pain reduction offered by TENS for low back pain was not deemed clinically important. In a review of the literature looking at the effectiveness of neurostimula- tion in the management of chronic pain by Hofmeister et al. (2020), these techniques were found to be effective for pain management in general. However, the authors encourage future studies to address effectiveness based on the timing of the initial intervention for its potential to reduce chronic pain symptoms.
MANUAL THERAPY SUPPORTING EVIDENCE
Manual Therapy
Evidence Level
Outcome
Chronic low back pain Spinal mobilization alone Spinal manipulation alone
Moderate to high
Positive
Moderate Moderate
Positive in short term
Manual therapy and exercise combination Chronic neck pain Cervical mobilization and manipulation combination Chronic shoulder pain—rotator cuff disorders Manual therapy and exercise combination Chronic shoulder pain—adhesive capsulitis Manual therapy and exercise combination
Positive in short and long term
Moderate
Positive in short term
Moderate
Positive
Moderate
Positive
Temporomandibular disorders Massage and myofascial release
Moderate to high
Positive Positive
Manual therapy and exercise combination
Moderate
Source: Adapted from Austin (2018)
Table 7
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